Little has changed in the area of health care over three decades

A psychiatrist who has worked with victims of Bhopal recounts how little has changed in the area of health care over three decades.

As we come to the 30th anniversary of the Bhopal gas disaster, there will be review and examination of what happened that night, how it changed the lives of the people of Bhopal, what efforts have been made to care for the survivors and what remains to be done.

I have been working with the people of Bhopal since 1984, to understand the mental health impact of the disaster and develop mental health care. This has given me an understanding of both their sufferings and of our failures in providing relief to the survivors.

In the years since the disaster, the most striking aspect of the health situation generally, and mental health care in particular, can be reflected in one word: ‘dissatisfaction’ – a euphemism for much that is experienced in Bhopal. Dissatisfaction among the affected people, the staff of voluntary organisations, the medical care providers as also the administrators. This dissatisfaction arises from the lack of information about the health impact of the disaster, the continuing medical needs of the population, the clinic-oriented medical care, the poor coordination of medical care, inadequacy of medical interventions and lack of rehabilitative services.

An important reference point in articulating the health needs, health rights and the approaches to achieve optimum health care of the survivors is the 9 August 2012 Supreme Court judgment, which was itself a result of over 14 years of legal battles. In the words of the judges: “All the gas victims are  entitled  to  greater  extent  of multi-dimensional health care, as their sufferings are in no way,  directly or indirectly, attributable to them.” Further the court ordered corrective solutions through “strengthening of the empowered monitoring committee, adequate research by the ICMR, computerisation  of  medical  information,  publication  of  ‘health booklets’ etc and complete  computerisation  of  the  medical information  in the government  as well as non-government  hospital/clinics, which should be completed within a period of three months from today.”

However, most of these directives remain unfulfilled and the population continues to suffer in silence.

For example, many people in the community are experiencing symptoms described in a recent book on the women of Bhopal, ‘The Let Down’ by Ms Swati Tiwari (in translation from Hindi) which records the years since the disaster as the woman survivors experienced it.

As one survivor put it,  “My body has become home to a number of unknown diseases”.

The book records:“Laxmi had many questions which are still open. She does not cry but she becomes aggressive to express her feeling, however, (and) loses temper. Her fists tighten. Her eyes become bloodshot. She earnestly wants to know what her fault was to deserve the ordeal of being witness to her own family perishing”.

“The pain of Pramila is that her in-laws have severed relations with her due to her illness. She was hardly ten at the time of the tragedy. She has lost her kith and kin. In course of time diseases caught hold of her”.

“From that day (of disaster), we never knew peace and happiness. His death wiped all the colours from our life. All our dreams and hopes lay shattered. Even today I shudder to think of it”.

The dissatisfaction with medical care is universal among the survivors. “Perhaps the doctors have also got fed up with checking up the gas-affected patients for so many years.” The women doing the rounds of the hospital said, “The doctors don’t bother to properly examine us. They try to put us off”.

I was part of the research efforts between 1985 and 1994 and have kept track of the health impact on the affected people. In 2003, two of us (Dr Amit Basu and I) wrote in the Economic and Political Weekly on the continuing mental health effect on the population.

We concluded that “no systematic effort has been made to tackle the mental health problems that were generated as an impact of the gas leak”. Sadly, this situation has not changed even in 2014!

Since 2010, I have been more actively studying the need of medical officers trained in the essentials of mental health care. When I restarted my engagement with the Bhopal population, what struck me was the utter lack of movement in providing the needed mental health care. What I saw in February 1985 was nearly exactly what I saw in October 2010 ~ a lot of suffering, a lack of awareness of the needs among care providers and unrelenting apathy of the administration.

Studies undertaken during this period showed that an inordinate majority of the persons studied had been ill through the 28 years, but had received very little in the nature of health care. At BMHRC, Bhopal, the tertiary care hospital specially built and exclusively for the survivors of the disaster, the care records revealed that there had been discontinuous and irregular treatment of a high percentage of psychiatric patients. There was no system to ensure longitudinal care and continuous follow-up.

In a community survey of the population conducted in  July 2012, 20 per cent of the 500 families surveyed had identifiable mental disorders and there was  higher mental morbidity among the poor, unemployed and those with physical diseases.

The current mental morbidity can be related to (i) people with post-disaster anxiety-depression, post-traumatic stress disorder, adjustment disorder conditions, directly related to the disaster of 1984; (ii) people with psychiatric disorders, attributable to the various life changes, family and occupational status, resulting directly (e.g., unemployment due to poor health conditions) and indirectly (e.g., loss of head of the family in the disaster) from the disaster experiences; (iii) people with chronic physical conditions like lung problems, diabetes, hypertension and cancer, with associated psychiatric disorders like depression, adjustment disorders; (iv) people with psychiatric disorders, that may not be directly related to the disaster .

A positive development in the mental health care situation in the city in the last three decades has been an increase in the number of mental health professionals in both the government and private sectors, along with in-patient care facilities at Gandhi Medical College, BMHRC, BEML and in the private sector. However, this is confined to the clinics with no care at the community level. In the last three decades, there have been many lapses in the assessment of disability, compensation provided (for instance, coverage, categorisation, amount), and rehabilitation, leaving the affected community “dissatisfied”. There has been no continuing research to understand the changing morbidity, adequacy of the care provided and efficacy of the different interventions. In the area of services, there is inadequacy in providing longitudinal mental health care to all persons with mental disorders, not linking primary health care with mental health care, lack of rehabilitation, no public mental health education, leaving it to self-care, and use of psychosocial interventions. Poor coordination with voluntary organisations has resulted in significant mistrust.

The experience in Bhopal speaks of collective amnesia about the sufferings of the survivors. There has been an inexcusable abandonment of survivors at all levels. Thirty years after the disaster, neglect has not been cast aside. Recognition of health needs, including mental health needs, is yet to happen, and care is still to become organised, comprehensive, continuous, coordinated and compassionate.  This situation demands to be remedied.

(The writer, a professor of psychiatry, has been associated with the people of Bhopal since the disaster. He has been a member of various government initiatives and is co-editor of a manual of mental health care for Bhopal victims. In 2011-13, he spent half his time in Bhopal making sense of what has happened in the arena of mental health after the disaster.)

by Srinivasa Murthy